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Pediatric Traumatic Brain Injury: A Silent Epidemic

Traumatic brain injury (TBI) is the leading cause of death and disability in children and a silent epidemic worldwide. In the US, one in five children experience a TBI before they reach the age of 16 years. TBI is a disruption to the normal function of the brain caused by a bump, blow or jolt to the head and is associated with developmental delay, lost school days, and higher rates of depression and suicide. Based on the current best estimates, 56,800 children suffer a severe TBI each year from falls, child abuse and motor vehicle collisions resulting in 7,000 deaths. Of those who survive, 60% will experience a lifetime disability. Average lifetime cost of care can be as high as $2 million per child. As a nurse practitioner and researcher I have seen first-hand the devastating effects of TBI, along with the disparity in outcomes among children with TBI. Severe TBI management focuses on promoting neuroprotection to minimize ongoing brain injury and preventing co-morbidities as a result of the brain’s disrupted function.

In 2018, the US Centers for Disease Control and Prevention (CDC), in collaboration with the National Institutes of Health (NIH), published the Report to Congress: The Management of Traumatic Brain Injury (TBI) in Children, to review the public health burden and to make recommendations for the future management and treatment of this population. Gaps and opportunities are identified within the report, including our insufficient and poor understanding of the injury, which limits medical management. One example of this significant limitation is that approximately 35% of children with TBI are not initially treated at a trauma center. Although guidelines have been published for almost two decades, few (if any) therapies are supported by compelling evidence to mandate their use.

The Brain Trauma Foundation convened a group of pediatric TBI clinical and research experts in late 2016. As a scientist studying pediatric TBI I was asked to join the team of international experts to examine the more recent evidence. This resulted in The Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, published in Pediatric Critical Care Medicine in 2018, which provides updated evidence-based recommendations applicable to the ICU management of children with severe TBI. It also directly addresses some of the previous gaps in pediatric TBI care. The updated guidelines reflect the addition of nearly 50 research studies, and include eight new or revised treatment recommendations for health care providers, that range from the use of intracranial monitoring to the use of hypertonic saline, to reduce acute brain swelling. An executive summary of the guidelines were published in the two journals: Pediatric Critical Care Medicine and Neurosurgery, in March 2019. To promote the use of these TBI guidelines, the full guidelines are available for free online via Pediatric Critical Care Medicine (https://journals.lww.com/pccmjournal/Fulltext/2019/03001/Guidelines_for_the_Management_of_Pediatric_Severe.1.aspx). These guidelines provide the most current scientific evidence in the care and treatment of children who present with a serious brain injury. They will help save lives and improve health outcomes in children with severe TBI.

Although these guidelines provide the most current evidence in approaches to treat children with severe TBI, one very important gap in the 3rd edition of the guidelines is the paucity of studies using omic technologies. This void in omic research among pediatric patients with TBI reduces our capability to deeply phenotype (i.e., precise and comprehensive analysis of phenotypic abnormalities) these children and to identify those who maybe at higher risk for ongoing brain injury and greater neurologic disabilities. For this reason my research has heavily focused on the inclusion of omics to identify biological underpinnings. International studies such as “Approaches and Decisions in Acute Pediatric TBI Trial” (ADAPT), which evaluated the impact of interventions on the outcomes of children with severe TBI may begin to reveal the most effective therapeutic approaches but unfortunately they lack an omic connection. Yet international funding agencies, such as the International Initiative for Traumatic Brain Injury Research has acknowledge the importance of biospecimen collection. Ultimately, there is a need for a directive that prospective pediatric studies in TBI include omic technologies to promote deep phenotyping. Deeply phenotyping children with TBI will avail a path to omic-influenced interventional trials and personalized rehabilitation care. Thereby addressing and perhaps more importantly mitigating the increasingly daunting public health challenge of pediatric TBI.    

 

References:

  • Centers for Disease Control and Prevention. Report to Congress: The Management of Traumatic Brain Injury in Children, National Center for Injury Prevention and Control. Division of Unintentional Injury Prevention. Atlanta, GA. 2018.
  • Schneier AJ, Shields BJ, Hostetler SG, Xiang H, Smith GA. Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States. Pediatrics. 2006;118:483–492. PMID: 16882799.
  • Lancet. The burden of traumatic brain injury in children. The Lancet. 2018;391(10123):813. PMID: 29508730.
  • Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic brain injury–related emergency department visits, hospitalizations, and deaths — United States, 2007 and 2013. MMWR Surveill Summ. 2017;66(SS-9):1–16. PMID: 28301451.
  • Reuter-Rice, K., Eads, J., Berndt, S., & Bennett, E. State of the Science of Pediatric Traumatic Brain Injury: Biomarkers and Gene Association Studies. Annu Rev Nurs Res. 2015;33(1):185-217. DOI: 10.1891/0739-6686.33.185. PMID: 25946386.
  • Kochanek, P.M., Tasker, R.C., Carney, N., Totten, A.M., Adelson, P.D., Selden, N.R., Davis-O’Reilly, C., Hart, E.L., Bell, M.J., Bratton, S.L., Grant, G.A., Kissoon, N., Reuter-Rice, K.E., Vavilala, M.S & Wainwright, M.S. Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary. Neurosurgery. 2019 Mar 2. pii: nyz051. DOI: 10.1093/neuros/nyz051. [Epub ahead of print]. PMID: 30822776.
  • Kochanek, P.M., Tasker, R.C., Carney, N., Totten, A.M., Adelson, P.D., Selden, N.R, Davis-O'Reilly, C., Hart, E.L., Bell, M.J., Bratton, S.L., Grant, G.A., Kissoon, N., Reuter-Rice, K.E., Vavilala, M.S., Wainwright, M.S. Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines. Pediatr Crit Care Med. 2019 Mar;20(3S Suppl 1):S1-S82. DOI: 10.1097/PCC.0000000000001735. PMID: 30829890.
  • Kochanek, P.M., Tasker, R.C., Bell, M.J., Adelson, P.D., Carney, N, Vavilala, M.S., Selden, N.R., Bratton, S.L., Grant, G.A., Kissoon, N., Reuter-Rice, K.E., Wainwright, M.S. Management of Pediatric Severe Traumatic Brain Injury: 2019 Consensus and Guidelines-Based Algorithm for First and Second Tier Therapies. Pediatr Crit Care Med. 2019 Mar;20(3):269-279. DOI: 10.1097/PCC.0000000000001737. PMID: 30830015.
  • Kochanek, P.M., Tasker, R.C., Carney, N., Totten, A.M., Adelson, P.D., Selden, N.R., Davis-O’Reilly, C., Hart, E.L., Bell, M.J., Bratton, S.L., Grant, G.A., Kissoon, N., Reuter-Rice, K.E., Vavilala, M.S & Wainwright, M.S. Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary. Pediatr Crit Care Med. 2019 Mar;20(3):280-289. DOI: 10.1097/PCC.0000000000001736. PMID: 30830016.
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